Postpartum depression

OB/GYN Module Training Conference

May 16, 2005

Elyse R. Park, Ph.D.

Massachusetts General Hospital/Harvard Medical School

Prevalence

For women ages 15 to 44, depression is the leading cause of disease burden worldwide.

Being a mother of a young child increases the risk of depression and depressive symptoms.

Additional risk: Low SESMore than 1 child

Epidemiological and clinical studies suggest that 8-12% of women may experience postpartum depression, and elevated depressive symptoms may be present in 24% of mothers.

Maternal Depression

Maternal depression encompasses several DSM-IV diagnoses including postpartum depression (PPD) and major depressive disorder.

PPD occurs immediately after delivery and can last up to one year postpartum.

Women who experience postpartum depression are at higher risk of subsequent episodes of depression.

Impact of Maternal Depression

In addition, extensive research has shown the negative impact that maternal depression, experienced during the postpartum period and beyond, can have on children’s social, cognitive, and behavioral development.

Effects of Maternal Depression

Maternal depressive symptoms are associated with:

newborn irritability

sleep difficulties

attachment and parenting difficulties

delayed development

behavioral and school problems

impediment of parental prevention practices

Women’s Medical Care Use

Lack of recognition and treatment of depression is more pervasive and the consequences potentially more serious for mothers of young children.

Women are likely to be overlooked because of their pattern of medical care use.

An examination of utilization patterns of women with children less than 36 months in the National Health Interview Survey by Auinger at the University of Rochester Child Health Research Center showed that 13% of these women had no medical care contacts in the previous 12 months and an additional 15% had only one visit.

Diagnosing maternal depression

Physicians often underdiagnose and undertreat depression.

25-50% of depressed patients are not recognized at a primary care visit (Williams et al., 1999).

Although most PCPs endorse their role in diagnosing depression, fewer endorse a role in treatment of depression.

Clinician’s attitudes about depression

Clinicians’ attitudes about treating depression are influenced by their perceptions about mental illness, comfort level with discussing mental health issues, and fear of stigmatizing patients.

Other concerns are that patients might fail to acknowledge symptoms, reject a physician’s diagnosis, or be resistant to treatment recommendations (e.g. referral to a mental health provider).

Clinician’s Confidence & Depression

Although clinicians report being confident in being able to identify depression, they are not confident in their ability to counsel patients for depression.

Gerrity and colleagues (2001) developed the ‘Perceived Self-Efficacy in Diagnosing and Treating Depression’ scale. 71% of physicians had low self-efficacy scores.

Rates of being ‘very confident,’ by specialty:Family physicians (64%) General internists (33%)OB/Gyns (16%) Pediatricians (3%)

Maternal Depression

What are the types?

Who is susceptible?

What are signs and symptoms?

What are the causes?

What are the screening tools?

What are helpful resources?

Types of Depression: Major Depression

Major depression is characterized by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. A disabling episode of depression like this may happen only once, but more commonly people experience several in a lifetime.

Types of Depression: Dysthymia

Dysthymia, a less severe type of depression, involves long-term, chronic symptoms that are not disabling, but keep one from functioning well or feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Types of Depression: Postpartum Depression

Postpartum depression occurs within four weeks of childbirth. Most new mothers suffer from some form of the “baby blues.” Postpartum depression, in contrast, is major depression, thought to be triggered by changes in hormonal flows associated with having a baby.

Signs & Symptoms of PPD

Crying that lasts for days

Suicidal thoughts

Thoughts of harming the baby

Intense fatigue or sleeplessness

Feelings of hopelessness and helplessness

Lack of motivation/interest

Difficulty with daily functioning

Feelings of guilt, worthlessness, helplessness Loss of interest or pleasure in hobbies

Signs & Symptoms of PPD

Difficulty concentrating, remembering

Inability to think clearly

Weight loss or gain

Restlessness, irritability

Decreased energy, fatigue, feeling "slowed down"

Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Causes for PPD

Physical changes

Hormone levels fluctuate - levels of estrogen and progesterone drop dramatically

Changes in blood pressure and your immune system

Causes for PPD

Emotional factors

Sleep difficulty & feeling overwhelmed can be exacerbated by:

• A sense of lost identity • An unsatisfying birth experience (e.g.

medical complications)• Anxiety, doubts or unrealistic expectations• Feeling less attractive • Feeling less in control over your life

Causes for PPD

Lifestyle influences A baby with a high level of needs

Exhaustion from caring for a new baby or multiple children

Financial problems

Lack of support from partner, family or friends

Postpartum pain or delivery complications

Problems with breast-feeding

Relationship difficulties

Treatment for PPD

Antidepressant medications

Many women with postpartum depression are treated with antidepressants called selective serotonin reuptake inhibitors (SSRIs), which seem to work by increasing the availability of the neurotransmitter serotonin in your brain.

Studies suggest that they're just as effective as older-generation antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs), but have fewer side effects.

Commonly prescribed SSRIs: paroxetine (Paxil) and sertraline (Zoloft).

Treatment for PPD

Counseling Short-term counseling can be effective treatment for

PPD. If symptoms of postpartum depression are

mild, psychotherapy may be all that's needed. The number of sessions required typically

ranges from six to 12. More severe cases of postpartum depression

typically require both psychotherapy and medications.

Treatment for PPD

Hormone therapy

Using an estrogen patch — a patch containing estrogen that you wear on your skin — can help counteract the rapid drop in estrogen that accompanies childbirth.

Risks: decreased milk production blood clot in the legs

EPDS

Developed at health centers in Livingston and Edinburgh.

10 short statements.

The mother underlines which of the four possible responses is closest to how she has been feeling during the past week.

Administration time: less than 5 minutes.

EPDS detection rates

Detection PrevalenceStudy Rate by EPDS SettingBarnett,1993 1.0% 39.0% Mothercraft Hospital

Bagedahl, 1998 2.0% 14.5% Well Baby Visits

Bryan, 1999 3.7% 6 week ob/gyn visit

Evins, 2000 6.3% 35.4% 6 week ob/gyn visit

Morris-Rush, 2003 13.0% 22.0% 6 week ob/gyn visit

Chaudron, 2004 4.0% 27.0% Well Baby Visits

EPDS Instructions

1) The mother is asked to underline the response which comes closest to how she has been feeling in the previous 7 days.

2) All ten items must be completed.

3) The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

4) The EPDS may be used at 6-8 weeks to screen postnatal women.

Websitehttp://www.nlm.nih.gov/medlineplus/postpartumdepression.html

• Overview of PPD• Diagnosis/Symptoms • Treatment • Coping • Clinical Trials • Mental Health Directories • Mental Health Organizations • Statistics for Depression in Women

Study Goal

The goal of this study is to obtain pilot data on the impact of depressive and anxiety symptoms on postpartum relapse.

Summary

The proposed research addresses the need to deepen our understanding about the effect of mood symptoms on postpartum tobacco use.

Throughout the 3-month postpartum period, we will look at the prevalence and impact of depression and anxiety symptoms among a cohort of women who were smokers prior to their pregnancy and quit upon learning about their pregnancy.

Purpose

To examine:

1) the prevalence of anxiety and depression among women who had remained quit during their pregnancy

2) when, in the postpartum period, increases in depression and anxiety symptoms and smoking relapse may occur

3) factors related to postpartum relapse

Purpose

Among a subset of women with elevated depression and/or anxiety symptoms, we will qualitatively explore:

1) mood symptoms experienced

2) attributions for mood changes and/or relapse

3) coping mechanisms and support

4) stressors

Study Rationale

Of women who do quit approximately two-thirds relapse within the first 3-6 months postpartum.

Among smokers, depression and stress are commonly cited barriers to smoking cessation and triggers for smoking and relapse, and perceived stress is related to less favorable cessation outcomes.

Studies conducted with pregnant women show that women who quit smoking upon learning that they are pregnant have lower levels of stress and depressive symptoms compared to women who continue smoking during their pregnancy.

Study Rationale

Since the postpartum period is a time when women are vulnerable to mood fluctuations, an examination of the relationship between mood and smoking behavior during this time is of particular importance.

To date no study has conducted an in-depth look at the role of depression and anxiety in postpartum relapse.

The purpose of this study is to determine if and when mood plays a role in relapse and guide the development of a postpartum relapse prevention intervention.

Study Population

Inclusion criteria Postpartum women identified recent quitters are eligible for the study if they:

smoked within six months prior to conception but did not smoke during the last month of pregnancy

have access to a telephone are at least 16 years of age speak English

Exclusion criteria current major depression or a history of other severe

psychiatric illness a newborn with a major congenital anomaly or <28

weeks’ gestation.

Design

Preliminary longitudinal cohort study using both quantitative and qualitative methods.

We will enroll 60 postpartum women at delivery.

Surveys administered : at delivery, 2 weeks, 4 weeks, 6 weeks, and 3-months.

Subjects who relapse or meet criteria for either mild depression (BDI >9) or anxiety (BAI>9), will also be interviewed qualitatively at the 4-week and 3-month period.

Study DesignRecruitment at delivery

Eligible Ineligible: Current Major Depression

Psychiatric historyNewborn < 28

weeks/congenital anomaly

Enroll/consent Refuse

BL survey

2 week survey

4 week survey

6 week survey

3 month survey

+++++++++

+++++++++

Qualitative interview if BDI or BAI > 9

Qualitative interview if BDI or BAI > 9

Measures

Survey period (in weeks)

Measures BL 2 4 6 12

Demographics

Age x

Marital Status x

Education x

Race/ethnicity x

Parity x

Insurance x

Breastfeeding intention x

Length of time breastfed x

Measures

Survey period (in weeks)

Measures BL 2 4 6 12

Smoking information

Prepregnancy smoking ratex

Smoking status x x x x x

Smoking rate (relapsers) x x x x

Smoking in environment x x

Motivation to stay quit x x

Measures

Survey period (in weeks)

Measures BL 2 4 6 12

Psychosocial

Confidence to stay quit x x x x x

Social support x x x x x

Weight concern x x x x x

Stressors x x x x x

Mood

BDI x x x x x

BAI x x x x x

SCID x x

Qualitative questions x x

Primary Aim

To compare rates of depression and anxiety experienced by relapsed smokers versus continued quitters.

H1. At 3-months postpartum, significantly more relapsers will experience mild depression (BDI score > 9) or anxiety (BAI score >9) symptoms compared to women who have remained quit.

Secondary Aim

To repeatedly assess postpartum mood symptoms and smoking status to determine at what time mood symptoms increase and relapse occurs.

H2a. An increase in mood symptoms, during the first 12 weeks postpartum, will be associated with relapse to smoking.

Secondary Aim Aim: To determine if baseline mood or increases in mood symptoms are associated with increased risk of relapse.

H2b. Relapse by 12 weeks will be associated with: depressed/anxious baseline mood increases in mood symptoms

Controlling for: a high prepregnancy smoking rate high number of family and friends who smoke low support to stay quit low motivation to stay quit low confidence in ability to stay quit high weight concern

Qualitative Aims

Among a subset of women (n=approx. 18) with elevated mood and/or anxiety symptoms, the aims are:

To understand the mood symptoms (type of symptoms experienced, quality of symptoms, severity of symptoms).

To explore attributions for mood changes To examine support and coping skills that

women use to deal with mood. To explore postpartum stressors.

Qualitative Aims Among a subset of women who relapse (return to smoking >1 cigarette per week), the aims are:

To understand relapse episode

To explore attributions for relapse

To examine support and coping skills that women use to deal with staying quit

To explore postpartum stressors